Diagnosing and treating attentional difficulties: a nationwide survey

Psychostimulant prescribing trends in a paediatric population in Ireland: a national cohort study

Background

Psychotropic paediatric prescribing trends are increasing internationally. The aim of this study is to examine the prevalence and secular trends in psychotropic prescribing in Irish children and adolescents between 2002 and 2011.

Methods

Data was obtained from the Irish General Medical Services (GMS) scheme pharmacy claims database from the Health Service Executive Primary Care Reimbursement Services (HSE-PCRS). Prescribing rates per 1000 eligible population and associated 95 % confidence intervals (CIs) were calculated across years (2002–2011), age groups (0–4, 5–11, 12–15 years) and gender. Rates of concomitant prescriptions for psycholeptics and antidepressants were also examined. The total expenditure costs were calculated and expressed as a percentage of the cost of all prescriptions for this age group (≤15 years).

Results

In 2002, 3.77/1000 GMS population (95 % CI: 3.53–4.01) received at least one psychostimulant prescription and this rate increased to 8.63/1000 GMS population (95 % CI: 8.34–8.92) in 2011. Methylphenidate was the most frequently prescribed psychostimulant. For both males and females the prevalence of medication use was highest among the 12–15 year old group. On average, a psycholeptic medication was prescribed to 8 % of all psychostimulant users and an antidepressant was concomitantly prescribed on average to 2 %. Total expenditure rose from €89,254 in 2002 to €1,532,016 in 2011.

Conclusions

The rate and cost of psychostimulant prescribing among GMS children and adolescents in Ireland increased significantly between 2002 and 2011. Further research is necessary to assess the safety, efficacy and economic impact of concomitant psychotropic prescribing in this population.

Negotiating parental accountability in the face of uncertainty for attention-deficit hyperactivity disorder

Despite extensive research into attention-deficit hyperactivity disorder (ADHD), parents' constructions of their children's behaviors have received limited attention. This is particularly true outside North American contexts, where ADHD is less established historically. Our research demonstrates how United Kingdom parents made sense of ADHD and their own identities postdiagnosis. Using discourse analysis from interviews with 12 parents, we show that they drew from biological and social environmental repertoires when talking about their child's condition, paralleling repertoires found circulating in the United Kingdom media. However, in the context of parental narratives, both these repertoires were difficult for parents to support and involved problematic subject positions for parental accountability in the child's behavior. In this article we focus on the strategies parents used to negotiate these troublesome identities and construct accounts of moral and legitimate parenting in a context in which uncertainties surrounding ADHD existed and parenting was scrutinized.

Executive impairment determines ADHD medication response: implications for academic achievement

Methylphenidate (MPH) often ameliorates attention-deficit/hyperactivity disorder (ADHD) behavioral dysfunction according to indirect informant reports and rating scales. The standard of care behavioral MPH titration approach seldom includes direct neuropsychological or academic assessment data to determine treatment efficacy. Documenting "cool" executive-working memory (EWM) and "hot" self-regulation (SR) neuropsychological impairments could aid in differential diagnosis of ADHD subtypes and determining cognitive and academic MPH response. In this study, children aged 6 to 16 with ADHD inattentive type (IT; n = 19) and combined type (n = 33)/hyperactive-impulsive type (n = 4) (CT) participated in double-blind placebo-controlled MPH trials with baseline and randomized placebo, low MPH dose, and high MPH dose conditions. EWM/ SR measures and behavior ratings/classroom observations were rank ordered separately across conditions, with nonparametric randomization tests conducted to determine individual MPH response. Participants were subsequently grouped according to their level of cool EWM and hot SR circuit dysfunction. Robust cognitive and behavioral MPH response was achieved for children with significant baseline EWM/SR impairment, yet response was poor for those with adequate EWM/ SR baseline performance. Even for strong MPH responders, the best dose for neuropsychological functioning was typically lower than the best dose for behavior. Findings offer one possible explanation for why long-term academic MPH treatment gains in ADHD have not been realized. Implications for academic achievement and medication titration practices for children with behaviorally diagnosed ADHD will be discussed.

Attention Deficit Hyperactivity Disorder: New Ways of Working in Primary Care

Children diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) and prescribed pharmacotherapy require ongoing regular follow-up for many years. Recent literature outlining the role of primary care in the ongoing medication monitoring of children and young people with ADHD is reviewed. We propose that a General Practitioner with a Specialist Interest (GPwSI) model could be developed in relation to ADHD to ensure that shared care arrangements between CAMHS and primary care for children with ADHD are in place. Clinical materials to support GPs in this new role are described.

Differences between subtypes of children with ADHD and simple attentional difficulties during an initial assessment

OBJECTIVE

To examine differences between subtypes of children with attention-deficit/hyperactivity disorder (ADHD), simple attentional difficulties and situational ADHD during an initial assessment.

METHOD

In a single-centre study examination data of 205 children who had an initial assessment between January 1, 2002 and December 31, 2003 were retrospectively analyzed. The groups of children were compared with respect to their history features, neuromotor deficits, neuropsychological performance, and comorbid behavioural and developmental deficits by standardized test procedures and questionnaires.

RESULTS

Children with ADHD more frequently have a positive family history of attentional symptoms than non-ADHD children. There is no difference between these groups with respect to the associated behavioural problems. Children classified as ADHD show more neuromotor problems and neuropsychological deficits than children with non-ADHD attentional problems. Children with ADHD subtype hyperactive/impulsive demonstrate better neuropsychological performance than children with subtypes inattentive and combined. Children with situational home-only or school-only ADHD show no clear differences in neuromotor behaviour, comorbid problems or neuropsychological performance.

CONCLUSIONS

There are clear neuropsychological differences between children who fulfil the classification criteria of The Diagnostic and Statistical Manual of Disease, Fourth Revision (DSM-IV) for ADHD and children who are confronted daily with attentional difficulties, but do not fulfil the criteria for ADHD. In contrast, differences in behavioural comorbidities were not found, nor were differences found between home-only and school-only ADHD children.